NOTE: Spinal manipulative therapy (SMT) is not unique to chiropractic, it is also offered by qualified medical doctors, physiotherapists and osteopaths.

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AUTHORS' CONCLUSIONS: Cervical manipulation and mobilisation produced similar changes. Either may provide immediate - or short-term change; no long-term data are available. Thoracic manipulation may improve pain and function. Optimal techniques and dose are unresolved. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

“Within only a few months, two systematic reviews on the above subject were published [Schneider M, Vernon H, Ko G et al. Chiropractic management of fibromyalgia syndrome: a systematic review of the literature. J Manipulative Physiol Ther 2009; 32: 25–40, and Ernst E. Chiropractic treatment for fibromyalgia: a systematic review. Clin Rheumatol 2009; 28: 1175–78.] …The curious thing about these two articles is that their conclusions are quite different...Of course, it is as legitimate to evaluate one specific modality, e.g. spinal manipulation, as it is to assess a whole treatment package provided by chiropractors, e.g. ‘chiropractic management’. In the latter case, one would expect to see only trials included that were conducted by chiropractors in a chiropractic setting. This was the approach of my review but not of that by Schneider et al. For example, Schneider et al. included trials of acupuncture or exercise, which had nothing to do with chiropractic. Moreover, they included only some of the relevant trials while others were omitted. Their review was thus neither systematic nor was it specific to chiropractic. To publish reviews of that nature, is, in my view, misleading…In conclusion, several recent systematic reviews of ‘chiropractic management’ have drawn positive conclusions. Yet the hallmark therapy of chiropractors, spinal manipulation, is not supported by good evidence in the respective conditions. In my view, these reviews are therefore likely to mislead.” Edzard Ernst, Focus Alternative and Complementary Therapies [FACT] (December 2009)

"Some chiropractors claim that spinal manipulation is an effective treatment for infant colic. This systematic review was aimed at evaluating the evidence for this claim. Four databases were searched and three randomised clinical trials met all the inclusion criteria. The totality of this evidence fails to demonstrate the effectiveness of this treatment. It is concluded that the above claim is not based on convincing data from rigorous clinical trials." Ernst, E. Int J Clin Pract. (September 2009) [pdf]

"Previous research has shown that professional chiropractic organisations 'make claims for the clinical art of chiropractic that are not currently available scientific evidence…'. The claim to effectively treat otitis seems to be one of them. It is time now, I think, that chiropractors either produce the evidence or abandon the claim." Edzard Ernst in a letter to the International Journal of Clinical Practice (September 2009)

"None of the studies showed that real manipulation was more effective than sham-manipulation in improving lung function or subjective symptoms. It is concluded that, according to the evidence of the most rigorous studies available to date, spinal manipulation is not an effective treatment for asthma." Ernst, E. Respir Med. (29th July 2009)

[NOTE: In a letter to the Editor of the Health Service Journal on 26th July 2004, Margaret Coats, Chief Executive and Registrar of the UK General Chiropractic Council, claimed that there was a "wealth of research evidence that demonstrates the cost-effectiveness and efficacy of chiropractic". The letter may be viewed by visiting the Press Releases archive found in Publications section of the GCC's website: www.gcc-uk.org]

Concludes "The methodological quality of one of two trials examining chiropractic manipulation was good and neither trial found significant differences between chiropractic spinal manipulation and a sham manoeuvre on any of the outcomes measured."

Concludes that there is no convincing evidence to suggest that spinal manipulation is a recommendable treatment option for any medical condition. E. Ernst and P. H. Canter, Journal of the Royal Society of Medicine

Interpretation: "Patients with acute low back pain receiving recommended first-line care do not recover more quickly with the addition of diclofenac or spinal manipulative therapy….These results are important because both diclofenac and spinal manipulative therapy have potential risks and additional cost for patients. If patients have high rates of recovery with baseline care and no clinically worthwhile benefit from the addition of diclofenac or spinal manipulative therapy, then GPs can manage patients confidently without exposing them to increased risks and costs associated with NSAIDs or spinal manipulative therapy." Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, O Day R, et al., The Lancet 2007; 370:1638-1643 (November 2007) [pdf] [An accompanying editorial noted: (1) Systematic reviews had concluded that NSAIDS and spinal manipulation were more effective than placebos. However, the patients in the reviewed studies did not have optimum first-line care, and the apparent benefit was not large, and (2) Advice to remain active and prescription of paracetamol will be sufficient for most patients with acute low back pain. (Koes BW. Evidence-based management of acute low back pain. Lancet 370:1595-1596 2007)]

No evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain. Annals of Internal Medicine (June 2003) The definitive meta-analysis of spinal manipulation for back pain. "This is the most thorough and thoughtful analysis of this subject ever published…. According to a recent cost evaluation chiropractic care for back pain is about twice as expensive as medical care and we also know of serious and rare complications associated with spinal manipulation. Thus, spinal manipulation is an unlikely candidate for the treatment of choice for back pain….. Among other things, (this meta-analysis) should prompt those experts that are responsible for writing guidelines on therapy for back pain to check carefully whether their recommendations regarding spinal manipulation are truly evidence-based." E. Ernst, Focus on Alternative and Complementary Therapies (FACT), December 2003]

Four scholarly chiropractors have concluded that epidemiologic evidence does not support chiropractic's most fundamental theory. Since its inception, the vast majority of chiropractors have postulated that 'subluxations' (misalignments) are the cause or underlying cause of ill health and can be corrected with spinal 'adjustments'. After searching the scientific literature, the authors concluded: "No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal, this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability." T.A. Mirtz et al, Chiropractic & Osteopathy (2nd December 2009) [pdf]

"Controversy over the inclusion of spinal manipulation in NICE guidelines on back pain intensified this week after a study showed no benefit when it was added to standard care with painkillers…The study adds to mounting criticism over NICE guidelines on back pain. The controversy has already led to the British Pain Society ousting their president, Professor Paul Watson, a member of the guideline development group." Nigel Praities, Pulse (21st September 2009)

"In conclusion, the assumption that chiropractic spinal manipulation is an effective treatment for whiplash injury is not based on data from CCTs. Trial data are urgently needed. In their absence, positive recommendations do not seem responsible." Edzard Ernst, Focus on Alternative and Complementary Therapies (June 2009)

This review concludes that there is no evidence-based definition of maintenance care and the indications for and nature of its use remains to be clearly stated. The prevalence with which maintenance care is used has not been established. Efficacy and cost-effectiveness of maintenance care for various types of conditions are unknown. This conclusion is identical to that of a similar review published in 1996, namely that maintenance care is not well researched and that it needs to be investigated from several angles before the method is subjected to a multi-centre trial. Charlotte Leboeuf-Yde and Lise Hestbaek, Chiropractic and Osteopathy (8th May 2008)

"Currently, there are two types of chiropractors: those religiously adhering to the gospel of its founding fathers and those open to change. The core concepts of chiropractic, subluxation, and spinal manipulation, are not based on sound science. Back and neck pain are the domains of chiropractic but many chiropractors treat conditions other than musculoskeletal problems. With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition. Manipulation is associated with frequent mild adverse effects and with serious complications of unknown incidence. Its cost-effectiveness has not been demonstrated beyond reasonable doubt. The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt." Edzard Ernst, Journal of Pain and Symptom Management (February 2008) [FULL TEXT] [pdf]